Morbid obesity (also referred to as clinically severe obesity) is recognized as a major
public health risk throughout the world. In the U.S.A. alone, over four million people
suffer from this chronic disease. Much of the associated morbidity and mortality is
related to co-morbid conditions which include, but are not limited to, cardiac disease,
diabetes mellitus type II, obstructive sleep apnea, hypertension, dyslipidemia,
gastroesophageal reflux disease, stress urinary incontinence, arthritis of the weight
bearing joints, infertility and some cancers.

Surgica~ treatment of morbid obesity has been well established as being safe and
effective (1). Both short and long-term improvement of co-morbidities has been well
documented (2-7). Medical treatment for this disease has included dietary manipulation,
behavior modification and medications. These have been tried singularly and in
combinations, but with only limited long-term positive results. The National Institute of
Health consensus conference in 1991 established widely accepted guidelines and indications
for the surgical management of severe obesity (8). The indications for surgical management
of obesity are summarized below.

INDICATIONS FOR SURGERY

Surgical therapy should be considered for individuals who:

have a body mass index (BMI) of greater than 40 kg/m2

OR

have a BMI greater than 35 kg/m2 with significant co-morbidities.

AND

can show that dietary attempts at weight control have been ineffective.

PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS

The overall care of patients undergoing bariatric surgery (weight reduction surgery)
requires programs which address both perioperative care and long-term management. Careful
preoperative evaluation and patient preparation are critical. Patients should have a clear
understanding of expected benefits, risks, and long term consequences of surgical
treatment. Surgeons must be aware of the diagnosis and management of complications
specific to bariatric surgery. Patients require appropriate lifelong follow- up with
nutritional counseling and biochemical surveillance. Surgeons need to be aware of the
needs of severely obese patients in terms of facilities, supplies, equipment, staff and
procedures, and should plan the personal time, specialized staff and/or multi-disciplinary
referral system as required. This multi- disciplinary approach includes medical management
of comorbidities, dietary instruction, exercise training, specialized nursing care and
psychological assistance as needed. Post-operative management of co-morbidities should be
directed by the practitioner familiar with the operation performed and the changes
created.

SURGICAL TECHNIQUES

Bariatric surgical procedures are divided into two types, restrictive and
malabsorptive. With either type of procedure, follow up is imperative to monitor for
potential serious sequelae and operative failure. These operations should only be done
performed within the confines of an obesity treatment Bariatric program intent on
maintaining long-term follow-up as well as long-term outcomes evaluation.

The operations which have been most frequently performed are the Roux-en-Y gastric
bypass, vertical banded gastroplasty, the biliopancreatic diversion (BPD) and it's
variations, and the various gastric banding procedures (9-13). At the time of this
writing, the adjustable silicone gastric banding is limited in its use under FDA protocol.
The NIH conference of 1991 recognized the vertical banded gastroplasty and gastric bypass
procedures as acceptable procedures based on available outcome data. (8)

Minimally invasive techniques have been used in bariatric surgery since 1993. (14, 15).
Laparoscopic bariatric procedures rely on videoscopic technologies to allow surgeons to
perform accepted bariatric operations in a minimally invasive fashion. The benefits of a
laparoscopic approach appear to be similar to those realized with laparoscopic
cholecystectomy, including but not limited to a shorter recovery with an earlier return to
normal activity. In addition, wound complications such infections, hernias and dehiscences
appear to be significantly reduced.

The indications for laparoscopic treatment of obesity are the same as for open surgery,
as and have been outlined earlier in this document. Not all patients are suitable for
laparoscopic bariatric surgery, and conversion to an open bariatric procedure is sometimes
necessary. Surgeons must have the skills, experience and equipment necessary to convert to
and perform open bariatric operations.

Virtually all bariatric operations can be performed with laparoscopic techniques,
although advanced laparoscopic skills are required (14-20). For safe and effective
laparoscopic treatment of obesity, advanced laparoscopic skills, such as intracorporeal
knot tying, use of angled scopes to achieve multiple viewing angles, and two-handed organ
and tissue manipulation are required. Therefore, appropriate training in advanced
laparoscopic techniques is mandatory. These skills are most appropriately acquired through
a residency, fellowship, or courses which detail the indications for bariatric procedures,
the various operative approaches -both open and laparoscopic, and the advanced skills
necessary to perform these operations. Additionally, the long-term care of these patients
needs to emphasized and taught. Before attempting such a procedure independently, the
surgeon should be preceptored by a surgeon experienced in the techniques. Finally, these
procedures require a well-trained operating team familiar with the equipment' instruments
and techniques of bariatric surgery.

SUMMARY

Morbid obesity is a significant health concern. Medical management fails to sustain
weight loss, and management of the co-morbidities is expensive and often ineffective.
Bariatric surgery currently provides the only significant, sustained weight loss.
Laparoscopic techniques, based on their "open" counterparts, are available. When
performed by appropriately trained surgeons, laparoscopic approaches appear to hasten the
patient's recovery and return to normal function. Experience and training in bariatric
surgery, advanced laparoscopic surgery skills, and a commitment to long-term patient
management are required.